The impact of COVID-19 on acute ischemic stroke admissions: Analysis from a community-based tertiary care center.

BACKGROUND/OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on hospital admissions and outcomes in patients admitted with acute ischemic stroke. METHODS: Single-center retrospective analysis of patients admitted to the hospital with acute ischemic stroke, between December 1st, 2019 and June 30th, 2020. Outcomes were classified as none-to-minimal disability, moderate-to-severe disability, and death based on discharge disposition, and compared between two time periods: pre-COVID-19 era (December 1st, 2019 to March 11th, 2020) and COVID-19 era (March 12th to June 30th, 2020). We also performed a comparative trend analysis for the equivalent period between 2019 and 2020. RESULTS: Five hundred and seventy-five patients with a mean age (years±SD) of 68±16 were admitted from December 1st, 2019 to June 30th, 2020, with a clinical diagnosis of acute ischemic stroke. Of these, 255 (44.3%) patients were admitted during the COVID-19 era. We observed a 22.1% and 39.5% decline in admission for acute ischemic stroke in April and May 2020, respectively. A significantly higher percentage of patients with acute ischemic stroke received intravenous thrombolysis during the COVID-19 era (p = 0.020). In patients with confirmed COVID-19, we found a higher percentage of older men with preexisting comorbidities such as hyperlipidemia, coronary artery disease, and diabetes mellitus but a lower rate of atrial fibrillation. In addition, we found a treatment delay in both intravenous thrombolysis (median 94.5 min versus 38 min) and mechanical thrombectomy (median 244 min versus 86 min) in patients with confirmed COVID-19 infection. There were no differences in patients' disposition including home, short-term, and long-term facility (p = 0.60). CONCLUSIONS: We observed a reduction of hospital admissions in acute ischemic strokes and some delay in reperfusion therapy during the COVID-19 pandemic. Prospective studies and a larger dataset analysis are warranted.

A New Risk Index for Predicting Outcomes among Patients Undergoing Carotid Endarterectomy in Large Administrative Data Sets.

BACKGROUND: We developed and validated a new index to provide risk adjustment and to predict in-hospital patient mortality and other outcomes in patients undergoing carotid endarterectomy (CEA). METHODS: The primary endpoint was occurrence of stroke, cardiac complications, or death during hospitalization for CEA derived from the Nationwide Inpatient Sample. Multivariate logistic regression was performed to identify the effect of clinical and demographic factors on occurrence of the primary endpoint. Data from 2005 to 2006 (study period 1) were used to derive risk index score whereas data from 2007 to 2009 (study period 2) were used for validation of the risk index. RESULTS: A total of 120,633 patients with mean age in years [ ±SD] of 71.1[ ±9.5] (42.4% women) underwent CEA during the derivation period. The rate of occurrence of composite endpoint during study period 1 was 3.1%. Predictors of the composite endpoint were (odds ratio [OR], P value) as follows: age 70 years or older (1.15, .013 assigned 1 point), atrial fibrillation (3.18, <.0001 assigned 3 points), Congestive Heart Failure (CHF) (1.81, <.0001 assigned 2 points), cigarette smoking (1.64, <.0001 assigned 2 points), symptomatic status (1.87, <.001 assigned 2 points), and chronic renal failure (1.64, <.0001 assigned 2 points). When applied to the validation cohort (n = 71,222), patients with scores 0-1 (OR 1.6, 95% confidence interval [CI] 1.5-1.8), scores 2-3 (OR 4.0, 95% CI 3.8-4.3), scores 4-5 (OR 7.5, 95% CI 6.8-8.2), and scores greater than 5 (OR 10.9, 95% CI 9.8-12.2) had composite rates of endpoint. The receiver operating characteristic curve of the risk index was 68.5% [±SE 0.5%]. CONCLUSION: New risk index will assist in risk adjustment for analyses of outcomes in large administrative data sets for comparative studies involving patients undergoing CEA.

Rates of Adverse Events and Outcomes among Stroke Patients Admitted to Primary Stroke Centers.

BACKGROUND AND PURPOSE: To identify the beneficial effects of primary stroke centers (PSCs) certification by Joint Commission (JC), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to PSCs and those admitted to non-PSC hospitals in the United States. METHODS: We obtained the data from the Nationwide Inpatient Sample from 2010 and 2011. The analysis was limited to states that publicly reported hospital identity. PSCs were identified by matching the Nationwide Inpatient Sample hospital files with the list provided by JC. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease, 9th Revision, codes 433.x1, 434.x1). RESULTS: We identified a total of 123,131 ischemic stroke patients from 28 states. A total of 72,982 (59.3%) patients were admitted to PSCs. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to PSCs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], .8; 95% confidence interval [CI], .7-.8) and sepsis (OR, .7; 95% CI, .6-.8). Patients admitted to PSCs were more likely to receive thrombolysis (OR, 1.6; 95% CI, 1.5-1.7). The mean cost of hospitalization (95% CI) of the patients was significantly higher in patients admitted at PSCs compared with those admitted at non PSC hospitals $47621 (47099-48144) vs. $35229 (34803-35654), P < .0001). The patients admitted to PSCs had lower inpatient mortality (OR, .8; 95% CI, .8-.9) and were more likely to be discharged with none to minimal disability (OR, 1.1; 95% CI, 1.0-1.1). CONCLUSIONS: Compared with non-PSC admissions, patients admitted to PSCs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.

The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice.

BACKGROUND: Atrial fibrillation is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however, the outcomes of patients with atrial fibrillation undergoing CAS have not been fully examined. We sought to investigate the impact of atrial fibrillation on outcomes of CEA and CAS in general practice. METHODS: We analyzed the data from the National Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complication, postoperative mortality, and composite of these end points. Univariate and multivariate regression analyses were performed to determine, first, the association of atrial fibrillation (compared to without atrial fibrillation) and, second, the association of CEA (compared with CAS) in patients with atrial fibrillation with the occurrence of postoperative stroke, cardiac complication, or death. Covariates included in the logistic regression were the patient's gender, age, race/ethnicity, comorbid conditions, and symptom status (symptomatic vs asymptomatic status) and the hospital's characteristics. RESULTS: Of the total 672,074 patients who underwent CAS or CEA, 8.8% (95% confidence interval [CI], 8.7-8.9) of the procedures were performed in patients with atrial fibrillation. Atrial fibrillation was associated with an increased risk of postoperative stroke in patients undergoing CEA (n = 879 [1.7%]; P < .0001; odds ratio [OR], 1.57; 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial fibrillation undergoing CAS (OR, 1.43; 95% CI, 1.18-1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89-3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality (OR, 1.31; 95% CI, 1.08-1.59) in atrial fibrillation patients were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial fibrillation, in whom the composite end point was significantly lower in patients undergoing CEA. CONCLUSIONS: Our analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial fibrillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA.

Impact of onset-to-reperfusion time on stroke mortality: a collaborative pooled analysis.

BACKGROUND: Onset-to-reperfusion time has been reported to be associated with clinical prognosis. However, its impact on mortality remained to be assessed. Using a collaborative pooled analysis, we examined whether early mortality after successful endovascular treatment is time dependent. METHODS AND RESULTS: In a collaborative pooled analysis of 7 endovascular databases, we assessed the impact of onset-to-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes. Successful reperfusion was defined as complete or partial restoration of blood flow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modified Rankin Scale score, 0-2), 90-day excellent outcome (modified Rankin Scale score, 0-1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. A total of 480 cases with successful reperfusion (median time, 285 minutes) contributed to the present pooled analysis (120 with internal carotid artery occlusion and 360 with isolated middle cerebral artery occlusion). Increasing onset-to-reperfusion time was associated with an increased rate of mortality and intracerebral hemorrhage and with a decreased rate of favorable and excellent outcomes, without heterogeneity across studies. The adjusted odds ratio for each 30-minute time increase was 1.21 (95% confidence interval, 1.09-1.34; P<0.001) for mortality, 0.79 (95% confidence interval, 0.72-0.87) for favorable outcome, 0.78 (95% confidence interval, 0.71-0.86) for excellent outcome, and 1.21 (95% confidence interval, 1.10-1.33) for intracerebral hemorrhage. CONCLUSION: Onset-to-reperfusion time affects mortality and favorable outcome and should be considered the main goal in acute stroke patient management.

A critical analysis of intra-arterial thrombolytic doses in acute ischemic stroke treatment.

BACKGROUND: Intra-arterial thrombolytics (IAT) such as Alteplase, Tenecteplase, and Reteplase are currently used in patients with acute ischemic stroke in varying doses. We evaluated the relationship of IA thrombolytic dose with angiographic recanalization, intracerebral hemorrhage (ICH) rates, and clinical outcomes at three comprehensive stroke centers. METHODS: We stratified patients who underwent endovascular treatment into tertiles based on intra-arterial thrombolytic dose administered: lower tertile (range 1.5-5 mg), middle tertile (range 6-10 mg), and upper tertile (range 10.3-68.5 mg) of rt-PA equivalent. The rates of angiographic recanalization, ICH, and favorable clinical outcomes (discharge modified Rankin score [mRS] = 0-2) were ascertained and compared within the three tertiles. Logistic regression analyses were performed to determine the association between IA thrombolytic dosages and angiographic recanalization, ICH, and favorable clinical outcomes after adjusting for potential confounders. RESULTS: A total of 197 patients were treated with IAT; mean age ±SD was 65.6 ± 16 years; 105 (53.3%) were women. Ninety-one (46.2%) patients received both IVT and IAT. IA rt-PA equivalent dose was not different between the patients with and without ICH [mean (mg) ± SD, 9.8 ± 6.1 versus 9.8 ± 9.5, p = 0.9]. We did not find any relation between increasing doses of IAT (from 2 to 69 mg rt-PA equivalent) and symptomatic or asymptomatic ICH: (p = 0.1630) and (p = 0.6702), respectively. Multivariate analysis demonstrated that IAT dose was not associated with ICH (OR 1.0, 95% CI 0.97-1.07, p = 0.3919) or favorable outcome (OR, 1.00, 95% CI 0.95-1.06, p = 0.7375). In a subset analysis of IVT patients, total doses ranged from 48.2 to 149 mg and were not associated with either symptomatic (p = 0.23) or asymptomatic (p = 0.24) ICHs. CONCLUSION: Our study demonstrates that IAT in doses up to 69 mg is safe without any evidence of dose-related ICHs even in those patients who had received IVT.

Should ischemic stroke patients with aphasia or high National Institutes of Health stroke scale score undergo preprocedural intubation and endovascular treatment?

BACKGROUND: Presence of aphasia or severe neurologic deficits is considered an indication for preprocedural intubation (PPI) for endovascular treatment (ET) in acute ischemic stroke patients. We determined the feasibility, technical success rates, and outcomes of ET without PPI in 2 groups of patients: those with aphasia and those with an admission NIHSS score of 20 or more. METHODS: The rates of intraprocedural intubation (IPI), good functional outcome at discharge (modified Rankin Scale score of 0-2), mortality, and intracerebral hemorrhage (ICH) were compared between those who did or did not undergo PPI in the above-mentioned patient groups. RESULTS: A total of 60 (50%) of 120 patients with aphasia underwent ET without PPI; 6 of 60 patients required IPI. The odds of any ICH (odds ratio [OR] 6.3) and in-hospital mortality (OR 9.3) were significantly higher in those undergoing PPI. In the second analysis, 36 (39%) of 93 patients with an NIHSS score of 20 or more underwent ET without PPI; 6 of 57 patients required IPI. The risk of any ICH (OR 7.6) and in-hospital mortality (OR 5.0) was higher among patients who underwent PPI. The rates of good outcome at discharge were significantly lower among patients with aphasia (OR .1, 95% confidence interval [CI] .04-.2) or those with an NIHSS score of 20 or more (OR .07, 95% CI .005-.9) with PPI compared with those without PPI. CONCLUSIONS: Despite the risk of IPI, patients with aphasia or an admission NIHSS score of 20 or more who underwent ET with PPI had lower rates of good outcomes and higher rates of ICH and death.

Impact of advanced healthcare directives on treatment decisions by physicians in patients with acute stroke.

BACKGROUND: The implementation of advanced healthcare directives, prepared by almost half of the adult population in United States remains relatively under studied. We determined the impact of advanced healthcare directives on treatment decisions by multiple physicians in stroke patients. METHODS: A deidentified summary of clinical and radiological records of 28 patients with stroke was given to six stroke physicians who were not involved in the care of the patients. Each physician independently rated 28 treatment decisions per patient in the presence or absence of advanced healthcare directives 1 month apart to allow memory washout. The percentage agreement to treat/intervene per patient and proportion of treatment withheld as a group were estimated for each of the 28 treatment decision items. We also determined the interobserver reliability between the two raters (attorneys) in interpretation of six items characterizing the adequacy of documentation within the 28 advanced healthcare directives. RESULTS: The percentage agreement among physician raters for treatment decisions in 28 stroke patients was highest for treatment of hyperpyrexia (100%, 100%) and lowest for ICU monitoring duration based on family-physician considerations outside of accepted criteria within institution (68%, 69%) in presence and absence of advanced healthcare directives. The physician rater agreement in choosing "yes" was highest for "routine-complexity" treatment decisions and lowest for "moderate-complexity" treatment decisions. The choice of withholding treatment in "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions was remarkably similar among raters in presence or absence of advanced healthcare directives. The only treatment decision that showed an impact of advanced healthcare directives was ICU monitoring withheld in 32% of treatment decisions in presence of directives (compared with 8% in the absence of directives). IV medication and defibrillation for cardiac arrest was withheld in 29% (compared with 19%) of the treatment decisions in the presence of advanced healthcare directives. The two attorney raters found the description of acceptable outcome inadequate in 14 and 21 of 28 advanced healthcare directives reviewed, respectively. The overall mean kappa for agreement regarding adequacy of documentation was modest (43%) for "does the advanced healthcare directive specify which treatments the patient would choose, or refuse to receive if they were diagnosed with an acute, terminal condition?" and lowest (3%) for "description of acceptable outcome." CONCLUSIONS: We did not find any prominent differences in most "routine-complexity," "moderate-complexity," or "high-complexity" treatment decisions in patient management in the presence of advanced healthcare directives. Presence of advanced healthcare directives also did not reduce the prominent variance among physicians in treatment decisions.

Epidemiological and clinical features of moyamoya disease in the USA.

BACKGROUND: An increasing number of cases of Moyamoya disease have been reported in the Japanese and US literature. We performed this study to quantify the rise in the prevalence of Moyamoya disease and to study the unique epidemiological and clinical features in the USA that may explain a change in incidence. METHODS: We analyzed data derived from patients entered in the Nationwide Inpatient Sample between 2005 and 2008, using ICD-9 codes for Moyamoya disease. Data including patient age, gender, ethnicity, secondary diagnosis, medical complications, and hospital costs were obtained. RESULTS: From 2005 to 2008 in the USA, there were an estimated 7,473 patients admitted with a primary or secondary diagnosis of Moyamoya disease. Patients admitted with Moyamoya disease were most frequently women and Caucasian. Overall, ischemic stroke was the most common reason for admission. Hemorrhagic stroke was more frequent in adults compared with children, 18.1 versus 1.5% (p < 0.05). CONCLUSION: The number of patients identified and admitted with Moyamoya disease has risen dramatically in the last decade. This study can lead to a better understanding of the disease pattern and healthcare consequences in the USA and suggests that pathophysiologic differences in Moyamoya disease may exist.

Rates and factors associated with admission in patients presenting to the ED with TIA in the United States-2006 to 2008.

BACKGROUND: The estimates of patients who present with transient ischemic attacks (TIA) in the emergency departments (EDs) of United States and their disposition and factors that determine hospital admission are not well understood. OBJECTIVE: We used a nationally representative database to determine the rate and predictors of admission in TIA patients presenting to EDs. METHODS: We analyzed data from the National Emergency Department Sample (2006-2008) for all patients presenting with a primary diagnosis of TIA in the United States. Samples were weighted to provide national estimates of TIA hospitalizations and identify factors that increase the odds of hospital admission including age, sex, type of insurance, median household income, and hospital type (urban teaching, urban nonteaching, and nonurban). Multivariate logistic regression analysis was used to identify independent predictors of hospital admission. RESULTS: There were 812908 ED visits for primary diagnosis of TIA; mean age (±SD), 70.3 ± 14.9 years; and 57.9% were women from 2006 to 2008. Of these ED visits, 516837 (63.5%) were admitted to the hospital, whereas 296071 (36.5%) were discharged from the ED to home. In the multivariate logistic regression analysis adjusting age, sex, and medical comorbidities, independent factors associated with hospital admissions were median household income $64000 or higher (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.22-1.44; P = .003), Medicare insurance type (OR, 1.19; 95% CI, 1.14-1.26; P < .0001), and metropolitan teaching hospital ED (OR, 2.17; 95% CI, 1.90-2.48; P < .0001). CONCLUSION: From 2006 to 2008, approximately 64% of all patients presenting with TIAs to the EDs within United States were admitted to the hospital. Factors unrelated to patients' condition such as median household income, insurance status, and ED affiliated hospital type play an important role in the decision to admit TIA patients to the hospitals.

Long-term outcomes of post-thrombolytic intracerebral hemorrhage in ischemic stroke patients.

BACKGROUND: Intracerebral hemorrhage (ICH) is an infrequent complication of intravenous recombinant tissue plasminogen activator (rt-PA) for the treatment of acute stroke. However, such ICH is an important reason for withdrawal of care because of lack of adequate data regarding long-term patient outcomes. OBJECTIVE: To report the long-term outcomes in patients with post-thrombolytic ICH. METHODS: We analyzed patient data from a randomized, placebo-controlled trial in patients with ischemic stroke presenting within 3 h of symptom onset. Baseline clinical characteristics and outcomes defined by modified Rankin scale (mRS) were ascertained at 3, 6, and 12 months after treatment in patients who suffered from post-thrombolytic ICH. Favorable outcome was defined by mRS of 0-3 and unfavorable outcome by mRS of 4-6 at 1 year. RESULTS: A total of 48 patients suffered post-thrombolytic ICH in the trial. Fourteen patients had favorable outcomes and 34 patients had unfavorable outcomes. Clinical characteristics did not have an impact on patient outcomes at 12 months. Patients with unfavorable outcomes were more likely to have an National Institutes of Health Stroke Scale (NIHSS) score ≥ 20 at 7-10 days after treatment (64 vs. 7 %, p < 0.0009). Patients with unfavorable outcomes were more likely to have a worsening of NIHSS score of >4 points at 7-10 days from their baseline NIHSS (44 vs. 0 %, p = 0.0006). CONCLUSION: Approximately 30 % of patients with post-thrombolytic ICH have favorable outcomes at 1 year which does not support early withdrawal of care. Ascertainment of NIHSS score and worsening of NIHSS score at 7-10 days may be necessary for accurate prognostic stratification.

Factors associated with favorable response to hyperbaric oxygen therapy among patients presenting with iatrogenic cerebral arterial gas embolism.

BACKGROUND: Iatrogenic cerebral arterial gas embolism (CAGE) is an uncommon but potentially a fatal condition. Hyperbaric oxygen (HBO2) therapy is the only definitive treatment for patients with CAGE presenting with acute neurologic deficits. METHODS: We reviewed medical records and neuroimaging of consecutive CAGE patients treated with HBO2 at a state referral hyperbaric facility over a 22-year period. We analyzed the effect of demographics, source of intra-arterial gas, signs and symptoms, results of imaging studies, time between event and HBO2 treatment, and response to HBO2 treatment in 36 consecutive patients. Favorable outcome was defined by complete resolution or improvement of CAGE signs and symptoms at 24 h after HBO2 treatment. Unfavorable outcome was defined by unchanged or worsened neurologic signs and symptoms or in hospital death. RESULTS: A total of 26 (72%) of the 36 patients had favorable outcome. Patients with favorable outcome were younger compared to those with unfavorable outcome (mean age [years, SD] 44.7 ± 17.8 vs. 58.1 ± 24.1, p = 0.08). Cardiopulmonary symptoms were significantly more common in CAGE related to venous source of gas compared to arterial source (p = 0.024) but did not influence the rate of favorable outcomes. Adjusted multivariate analysis demonstrated that time from event to HBO2 ≤ 6 h (positively) and the presence of infarct/edema on head computerized tomography (CT)/magnetic resonance imaging (MRI) before HBO2 (negatively) were independent predictors of favorable outcome at 24 h after HBO2 treatment [odds ratio (OR) 9.08 confidence interval (CI) (1.13-72.69), p = 0.0376, and (OR) 0.034 (CI) (0.002-0.58), p = 0.0200, respectively]. Two of the 36 patients were treated with thrombolytics because of acute focal deficits and suspected ischemia-one with intravenous and the second with intra-arterial thrombolysis. The latter patient developed fatal intracerebral hemorrhage. CONCLUSIONS: A high proportion of CAGE patients treated with HBO2 had favorable outcomes. Time-to-HBO2 ≤ 6 h increased the odds of favorable outcome, whereas the presence of infarct/edema on CT/MRI scan before HBO2 reduced the odds of a favorable outcome. Timely diagnosis and differentiation from thrombo-embolic ischemic events appears to be an important determinant of successful HBO2 treatment.

Validation of intracerebral hemorrhage-specific intensity of care quality metrics.

BACKGROUND: Given the considerable variation in care of patients with intracerebral hemorrhage (ICH) among centers that results in differences in outcome among these patients, a new intensity of care quality metrics has been proposed. This study aimed to validate the new ICH-specific intensity of care quality metrics. METHODS: A total of 50 consecutive patients with ICH who were admitted within 24 hours of symptom onset were identified. Twenty-six quality indicators related to 18 facets of care were incorporated into a metric providing the variable, definition of the variable, and quality parameter. A score of 1 point was assigned if the quality parameter met the threshold for appropriate performance or if the parameter was not applicable, creating a total score of up to 26 points. The predictive validity of the classification scheme was tested by using the bootstrap method. RESULTS: Fourteen of the 50 patients with ICH died during hospitalization (28%). The intensity of care quality metric score ranged from 17 points to 26 points. The mean score was higher in those who survived compared with those who died (23 ± 3 vs 21 ± 2; P = .02). Survival increased with tertile based on higher scores (100%, 67%, and 55%; P = .017). The receiver operating characteristic curve demonstrated a high discriminating ability of intensity of care quality metrics for in-hospital mortality (0.730, 95% confidence interval, 0.591-0.869) and a C-statistic of 0.91 (95% confidence interval, 0.90-0.92). CONCLUSIONS: Correlation of the new ICH-specific intensity of care quality metric with in-hospital mortality supports its broader use for improving and standardizing medical care among patients with ICH.

Outcomes of thrombolytic treatment for acute ischemic stroke in dialysis-dependent patients in the United States.

OBJECTIVE: To determine the outcomes of dialysis-dependent renal failure patients who had ischemic stroke and were treated with intravenous (IV) thrombolytics in the United States. METHODS: We analyzed the data from Nationwide Inpatient Sample (2002-2009) for all thrombolytic-treated patients presenting with acute ischemic stroke with or without dialysis dependence. Patients were identified using the International Classification of Disease, Ninth Revision, Clinical Modification codes. Baseline characteristics, in-hospital complications including secondary intracerebral hemorrhage (ICH), sepsis, pneumonia, pulmonary embolism, deep venous thrombosis, urinary tract infections, and discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the groups. RESULTS: Of the 82,142 patients with ischemic stroke who receive thrombolytic treatment, 1072 (1.3%) was dialysis dependent. The ICH rates did not differ significantly between patients with ischemic stroke with or without dialysis who received thrombolytics (5.2% versus 6.1%). The in-hospital mortality rate was higher in dialysis-dependent patients treated with thrombolytics (22% versus 11%, P≤.0001). After adjusting for age, sex, and comorbidities, dialysis dependence was associated with higher rates of in-hospital mortality in patients treated with thrombolytics (odds ratio, 1.92; 95% confidence interval, 1.33-2.78, P=.0005). CONCLUSIONS: The 2-fold higher odds of in-hospital mortality associated with administration of IV thrombolytics in dialysis-dependent patients who present with acute ischemic stroke warrant a careful assessment of risk-benefit ratio in this population.

Is there a decreased risk of intracerebral hemorrhage and mortality in obese patients treated with intravenous thrombolysis in acute ischemic stroke?

BACKGROUND: The current guidelines do not recommend increasing the dose of intravenous recombinant tissue plasminogen activator (IV rt-PA) for ischemic stroke patients weighing >100 kg. Obese patients are therefore receiving an IV rt-PA dose <0.9 mg/kg; however, the consequences of such underdosing are unknown. Our goal was to determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. METHODS: Data from all patients admitted to US hospitals between 2002 and 2009 who were treated with IV thrombolysis and who had a primary discharge diagnosis of stroke were included. The effect of obesity on rates of intracerebral hemorrhage and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. RESULTS: Of the 81,579 patients with ischemic stroke treated with IV rt-PA, 5174 (6.3%) were categorized as obese. The intracerebral hemorrhage rates in obese and nonobese patients were significantly different (4.5% v 6.3%; P = .01). After adjusting for age, sex, presence of hypertension, diabetes mellitus, location/teaching status and All Patient Refined Diagnosis Related Group severity scale, there was no difference in the rates of no to minimal disability between obese and nonobese patients (odds ratio [OR] 1.0; 95% confidence interval [CI] 0.8-1.2; P = .8). Obese patients had lower odds of in-hospital mortality (OR 0.6; 95% CI 0.5-0.8; P = .001) but also more likely to be discharged with moderate to severe disability (OR 1.2; 95% CI 1.01-1.3; P = .03). CONCLUSIONS: Obese patients receiving IV rt-PA treatment for acute ischemic stroke appear to have a higher survival rate most likely related to their decreased rates of intracerebral hemorrhage.

Combination of noninvasive neurovascular imaging modalities in stroke patients: patterns of use and impact on need for digital subtraction angiography.

BACKGROUND: The diagnostic work-up of acute stroke relies on the use of proper imaging studies. We sought to determine the use of a combination of 2 noninvasive tests, namely magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in diagnosing vascular lesions and the necessity for a subsequent digital subtraction angiography (DSA) for the definitive diagnosis. METHODS: Patients admitted to 2 comprehensive stroke centers between January 2008 and July 2010 who had an equivocal initial noninvasive test were reviewed. The proportions of patients who underwent CTA and MRA in combination and those who required additional DSA for definitive diagnosis were determined. The diagnostic yield and impact on management in patients with CTA and MRA combination was compared with patients who underwent CTA and MRA followed by DSA. RESULTS: Among a total of 1063 patients (mean age ± SD 63 ± 16), 384 (36%) underwent >1 vascular imaging study. There was no difference in the rates of cardiovascular risk factors and stroke subtype between different combination groups. The agreement between CTA and MRA was high (concordance 81%). Among the 164 patients who underwent both CTA and MRA, a DSA was required for resolution/confirmation in only 27 (16%) patients. Among these 27, DSA findings changed the clinical decision-making in 22 (82%) patients (11 stenotic severities and 11 diagnoses of arteriovenous fistula, aneurysm, or dissection). CONCLUSIONS: In our experience, a combination of CTA and MRA was frequently used in patients in whom the initial noninvasive imaging was determined insufficient. The combination of findings from CTA and MRA were considered adequate in a large portion of patients resulting in a lower requirement for DSA and higher treatment impact from DSA.

Safety and effectiveness of endovascular treatment after 6 hours of symptom onset in patients with anterior circulation ischemic stroke: a matched case control study.

BACKGROUND: Endovascular treatment within 6 hours of symptom onset appears to be beneficial in carefully selected patients with ischemic stroke. It is unclear whether endovascular treatment beyond 6 hours of symptom onset is safe and efficacious. METHODS: Over a 6-year period, 52 patients with acute ischemic stroke in the anterior circulation underwent emergent endovascular thrombolytic infusion and mechanical thrombectomy after 6 hours of symptom onset at 3 institutions. Their outcomes were compared to 52 placebo-treated patients matched by baseline National Institutes of Health Stroke Scale (NIHSS) score and nonlacunar anterior circulation location from the Trial of Org 10172 in Acute Stroke Treatment trial using a 1:1 ratio. Univariate and multivariate analyses were performed comparing the rates of symptomatic intracerebral hemorrhage, early neurologic improvement, favorable outcome at 7 days or discharge, and in-hospital mortality between the 2 groups. RESULTS: After adjustment for gender, time interval between symptom onset to treatment, hypertension, hyperlipidemia, and history of cigarette smoking, rates of neurologic improvement at 24 hours (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.43-3.1) and favorable outcome at 7 days or discharge (OR 1.39; 95% CI 0.47-4.05) were similar in the 2 groups. No differences in the rates of symptomatic intracerebral hemorrhage or death were found after adjusting for potential confounders. In an analysis limited to only those patients who underwent computed tomographic perfusion or magnetic resonance imaging before receiving endovascular treatment, the rate of favorable outcome at 7 days or discharge was similar between patients who underwent endovascular treatment and control patients (35.7% v 32.1%; P = .77). CONCLUSIONS: We did not observe any evidence of benefit in halting neurologic worsening or improving outcomes among patients undergoing endovascular treatment for treatment of an anterior circulation ischemic stroke after 6 hours of symptom onset. Strong evidence of both the safety and efficacy of emergent endovascular treatment when administered to patients with stroke in the anterior circulation is needed.

Adherence to guidelines by emergency medical services during transport of stroke patients receiving intravenous thrombolytic infusion.

BACKGROUND: The "drip and ship" paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). It remains controversial whether the settings within the emergency medical services (EMS) transport are adequate for IV rt-PA infusion. We sought to determine EMS adherence to guidelines during the transport of drip and ship AIS patients treated with IV rt-PA while being transferred to comprehensive stroke centers (CSCs) and the effect of nonadherence on outcome upon discharge. METHODS: A retrospective evaluation of patients transferred to our CSC was conducted to determine the rates of adherence to quality parameters during EMS transport with infusion of IV rt-PA. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 upon discharge. RESULTS: Among the 40 patients studied (55% men; mean age 71.9 ± 13.9 years), 38 patients received vital sign monitoring at 10- to 20-minute intervals. The mean transit time was 37.7 ± 20.2 minutes. Of the 39 patients with blood pressure (BP) monitoring, 7 patients had at least 1 episode of BP elevation above the recommended parameters (>180/105 mm Hg); only 1 of those was treated with an antihypertensive agent. Five of the 40 patients were considered to have worsened between the outside ED and CSC ED evaluations without IV rt-PA discontinuation during transfer. The rate of favorable outcome of patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mm Hg without antihypertensive treatment was similar to those who experienced neither event (41.7% and 35.7%; P = .736). CONCLUSIONS: Efforts are required to improve EMS adherence to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of the "drip and ship" paradigm.

Diagnosis of stroke by emergency medical dispatchers and its impact on the prehospital care of patients.

BACKGROUND: Emergency medical dispatchers represent the first line of communication with a patient, and their decision plays an important role in the prehospital care of stroke. We evaluated the rate and accuracy of stroke diagnosis by dispatchers and its influence in the prehospital care of potential stroke patients. METHODS: We analyzed the 2009 National Emergency Medical Services Information System. Study population was based on the diagnosis of stroke made by emergency medical technicians (EMT). This was then divided in those coded as stroke/cerebrovascular accident versus others reported by dispatchers and compared with each other. RESULTS: In all, 67,844 cases were identified as stroke by EMT, but transportation time was available for 52,282 cases that represented the final cohort. Cases identified as stroke by dispatchers were 27,566 (52.7%). When this group compared with stroke cases not identified by dispatchers, we found that the mean age was significantly higher (71.2 versus 68.6 years, P<.0001); advanced life support was dispatched more frequently (84% versus 72.8%, P<.0001), dispatchers offered help and instructions to the caller more frequently, and they arrived at a facility at a shorter time (41.8 versus 49.8 minutes, P<0001). Sensitivity and specificity for the diagnosis of stroke by dispatchers were 34.61 and 99.46, respectively. CONCLUSIONS: Recognition of symptoms and diagnosis of a potential stroke by dispatchers positively affect the care of patients by decreasing the arrival time to a hospital and providing the highest level of prehospital care possible. Education is needed to increase dispatcher's detection of stroke cases.

Determinants of neurologic deterioration and stroke-free survival after spontaneous cervicocranial dissections: a multicenter study.

Patients with spontaneous cervicocranial dissection (SCCD) may experience new or recurrent ischemic events despite antiplatelet or anticoagulant therapy. Treatment with stent placement is an available option; however, the literature on patient selection is limited. Thus, identifying patients at high risk for neurologic deterioration after SCCD is of critical importance. The present study examined the rate of neurologic deterioration in medically treated patients with SCCD and evaluated demographic, clinical, and radiologic factors affecting this deterioration. We retrospectively identified consecutive patients with SCCD over a 7-year period from 3 medical institutions, and evaluated the relationships between demographic data, clinical characteristics, and angiographical findings and subsequent neurologic outcomes. Neurologic deterioration was defined as transient ischemic attack (TIA), ischemic stroke, or death occurring during hospitalization or within 1 year of diagnosis. Kaplan-Meier curves were used to determine neurologic event-free survival up to 12 months. A total of 69 patients (mean age, 47.8 ± 14 years; 45 males) with SCCD were included in the study. Eleven patients (16%) experienced in-hospital neurologic deterioration (TIA in 9, ischemic stroke in 1) or death (1 patient). An additional 8 patients developed neurologic deterioration within 1 year after discharge (TIA in 5, ischemic stroke in 2, and death in 1). The overall 1-year event-free survival rate was 72%. Women (P = .046), patients with involvement of both vertebral arteries (P = .02), and those with intracranial arterial involvement (P = .018) had significantly higher rates of neurologic deterioration. Our findings indicate that neurologic deterioration is relatively common after SCCD despite medical treatment in women, patients with bilateral vertebral artery involvement, and those with intracranial vessel involvement.